Every finding on record at Good Samaritan Hospice and Palliative Care, Inc.

Observed in Tracer Activities. During the review of the organization's Emergency Operations Plan, it was identified that the organization had not evaluated the effectiveness of their emergency response plan following 2 of the 3 drills/exercises conducted over the past 3 years, thus there was no identification of deficiencies and opportunities for improvement. This was reviewed and validated with the Director of Patient Care Services designee. Observed in Tracer Activities. During the review of the organization's Emergency Operations Plan, it was identified that the organization had not evaluated the effectiveness of their emergency response plan following 2 of the 3 drills/exercises conducted over the past 3 years. This was reviewed and validated with the Director of Patient Care Services designee. Observed in Tracer Activities. During the review of the organization's Emergency Operations Plan, it was identified that the organization failed to evaluate the effectiveness of the emergency response plan following 2 of the 3 exercises/drills conducted over the past 3 years, thus subsequent emergency response exercises did not reflect modifications and interim measures. This was reviewed and validated with the Director of Patient Care Services designee. Observed in Tracer Activities. During the review of the organization's Emergency Operations Plan, it was identified that the organization failed to evaluate the effectiveness of the emergency response plan following 2 of the 3 exercises/drills conducted over the past 3 years, thus there were no modifications to the Emergency Operations Plan based on evaluations. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Record Review. In 3 or 4 records reviewed where the patients discharged alive, the organization did not respect the patient's right to elect and revoke hospice care. For example in RR#4 the patient's record indicates that the patient was discharged For Cause when the family chose to send the patient to the hospital for aggressive treatment, so there was no revocation form signed. In RR#7 the records indicates that the patient Revoked to seek treatment in the hospital but no revocation form was signed. In RR#8, the record indicates that the patient was discharged For Cause and family wishes, but there was no revocation form signed. This was reviewed and validated with the Patient Care Services designee.

Observed in Tracer Activities. Identified during the review of the organization's Quality Assurance Performance Improvement (QAPI) program, there were no current performance improvement activities, thus the organization had not selected performance activities that affect outcomes. For example during the record review it was identified that live discharges due to patients seeking aggressive treatment was a significant problem-prone area for the organization but had not been considered for improvement activities. This was discussed and validated with the Director of Patient Care Services designee.

Observed in Tracer Activities. Identified during the review of the organization's Quality Assurance Performance Improvement (QAPI) program, and in review of the QAPI data collection binder, there was no evidence that the organization acts when it does not achieve or sustain planned improvements. This was reviewed with the Director of Patient Care Services designee. Observed in Tracer Activities. Identified during the review of the organization's Quality Assurance Performance Improvement (QAPI) program, and in review of the QAPI data collection binder, there was no evidence that the organization evaluates actions to confirm that they resulted in improvements. This was reviewed with the Director of Patient Care Services designee.

Observed in Tracer Activities. Identified during the review of the organization's Quality Assurance Performance Improvement (QAPI) program, there was no evidence that the number and scope of annual performance improvement projects was based on the patient's needs and internal organization needs. For example, during review of the organization's data collected, the Surveyor identified only one entry in the data collection labeled (1) Performance Improvement Plan; Falls, during the past three (3) years. This was reviewed with the Director of Patient Care Services designee.

Observed in Tracer Activities. Identified during the review of the organization's Quality Assurance Performance Improvement (QAPI) program, there was no indication of current performance improvement projects being conducted, including the reasons for conducting, or measurable progress achieved. This was reviewed with the Director of Patient Care Services designee.

Observed in Tracer Activities. Identified during review of the Volunteer Program and in conversation with the Director of Patient Care Services designee, there have been no volunteer recruitment activities during the past three years: 2020, 2021, and 2022.